February 19, 2008

I hope that the temporary inconvenience of adjusting your browsers will be offset by access to more information relevant to healthcare collaboration, including peer-reviewed articles that I have written that you can download free of charge at http://healthcarecollaboration.com/articles/, shortly after I receive permission from the publishers.

Thank you for your interest and participation in the Healthcare Collaboration Blog.

The chapter that I particularly enjoyed was "Use Patient Navigation," where they cited the work of an oncologic surgeon, Dr. Harold Freeman, with patient navigators at Harlem Hospital. Patient navigators are knowledgeable healthcare professionals or volunteers who help cancer patients through the entire continuum of care. A trained navigator can:

prepare patients and identify barriers

assist with the logistics of care

facilitate referrals to physicians and community programs

help to find resources

provide emotional support

In patients treated for breast cancer at Harlem Hospital, the number of patients with localized disease increased from 51% to 79% after the navigator program, with a dramatic increase in 5-year survival from 39% to 70%.

As a cancer survivor, I wrote in "Chemotherapy from An Insider's Perspective," Lancet 1:1006-1009, 1982: "Surprise spits in the eye. Any event that occurs unpredictably, regardless of the cause, should be expected to produce feelings of helplessness and outrage.... The only times that I considered terminating chemotherapy prematurely were during these surprises, because each one made me feel as though the light at the end of the tunnel represented an oncoming train.... Intermittent desire to stop chemotherapy reflected my inability to cope with the unpredictable side-effects of treatment, not an objective calculation of the amount of medicine necessary for cure."

I think that we can benefit from well-trained advocates who guide us and provide emotional support. I would appreciate your responding to the following questions:

Are there other diseases than cancer where navigator programs are up and running

For those who have set up navigator programs, what lessons have you learned that you can share with our readers

Do you know of any programs where navigators go beyond working within the present system (or non-system) of fragmented care to improve processes of care

February 11, 2008

Maggie Mahar provided readers with a valuable service in "How Much Do We Really Know About Canadian Healthcare?", a post from Sara Robinson, a dual citizen of Canada and the US with first-hand information about both systems. Her post is a great example of policy analysis from the ground up. Sara points out that the Canadian system involves:

single-payer insurance

an average physician debt burden of approximately half of the $140,000 for US graduates

variation in wait times and physician access, increasing as one moves north from the urban areas in southern Canada

February 07, 2008

It seemed like such an easy task that day on rounds. I was a first-year surgical resident asked to remove a central venous catheter that was no longer necessary for monitoring. No one asked whether I had slept the previous night on call (I hadn't); this was a task that could be performed at a "spinal" rather than cerebral level, so I thought.

Taking off the dressing and cutting one of the sutures that held the catheter in place were easy tasks that I had done hundreds of times before. Unfortunately, as I maneuvered my scissors around the knot where it entered this 82 year-old patient's neck, he suddenly twisted, and I was left holding the short end. The remaining piece lodged in the right side of his heart.

I felt terrible as I called for help and apologized to the patient's attending surgeon, chief resident, family, nurses, and anyone else who would listen. They tried to console me by telling me about errors that they had made. It did not help. My self-confidence plummeted.

I jumped in the air with glee when told that a cardiologist had successfully removed the catheter from the right atrium with a wire snare. I was convinced that if the patient did not survive, I should resign from the program and worked tirelessly to help him recover. To this day, I remain grateful for the collaboration from all the healthcare professionals who helped him recover.

Decades later, I learned that I was on the "sharp" end of a systems error. Sure, I was the one who cut the catheter, but the resident who placed the line sewed it to the neck without leaving a loop into which I could easily insert my scissors; furthermore, he used an internal jugular (neck) rather than a subclavian approach. In retrospect, I could have asked a nurse to stabilize the patient's head and used a sharply pointed scalpel blade rather than scissors. This was truly an example of painful learning.

The marketplace: the perception of quality drives word-of-mouth feedback about organizations and practitioners and decision-making about where to go for diagnosis and treatment; the cost of treating certain complications, like hospital-acquired infection, contributes significantly to rising healthcare costs

The old paradigm of physicians and nurses taking care of clinical dimensions of care and hospital administrators taking care of finance and operations does not work any more. Quality and safety must become and remain a collaborative effort in which board members, hospital leaders, physicians, nurses,allied healthcare professionals, and patients and families reflect on and discuss openly how to come to a common vision on optimizing care for their community. Moreover, they need to set timely deadlines for implementation and monitor their progress at regular intervals.

What do you think?

What do we need to do to move beyond paying lip service to the business and humanitarian rationale for quality?

"The struggle still remains to connect the silos and get everyone on the same page.... It's not the fact that the silos exist that's the problem. It's their lack of coordination and conflicting metrics. The silo management approach does not work."

Porting the results to a 2 (high vs low value of relationship) x 3 table (promoters, passives, or detractors) allows one immediately to see whether a physician whose relationship is very important to an instiitution (for example, a neurosurgeon) places the same value on the relationship. If he places a much lower value than you do, it may take only a brief phone call to find out what is detracting from the relationship and correct it in a timely fashion.

A CEO in St. Louis used her assistant who managed the physicians' lounge to survey physicians monthly from the physicians' lounge using these two questions, which the assistant put into a spreadsheet to track responses over time:

"How likely are you to recommend this organization, service, or department to a friend or colleague?"

January 25, 2008

One way to analyze this question may lie in exploring the dual meaning of the word engagement. The yang, or positive aspect, involves interfacing with another person in a pleasant fashion, as in, "She engaged him in conversation," or "They are engaged to be married." The yin, or negative polarity, involves entanglement and conflict, as in "our army engaged the enemy."

Unfortunately, our systems of care do not seem to have progressed as rapidly, especially with regard to healthcare delivery. As Maggie Mahar wrote in Glenn Beck Gives Birth to a New Health Care Myth, "the behavior of health care professionals is inextricably linked to the health care system in which they work. Granted, it’s not as though there’s a simple, direct line from institutional design to the hearts and minds of doctors; but systems set incentives and define interests that ultimately encourage, reward, or penalize certain behavior."

I hope that this blog will serve as an eventual repository of results of experiments that improve delivery of services, decrease waste, and help people reconnect with the reasons that they chose healthcare careers in the first place.

If physicians and other healthcare professionals agree on the who (patients) and the why (to make a positive difference in patients' lives), the how becomes a life-long learning journey.

How do you see it:

in what ways can the common frustrations of being squeezed by stagnant or decreasing reimbursement in the face of rising expectations and burdensome regulations unite us rather than divide us

What can physicians learn from hospital leaders about building consensus and safeguarding organizational survival

What can hospital leaders learn from physicians about making high-stakes decisions in the face of limited information and limited time

How can both groups learn to work together and not personalize inevitable disappointments?

January 24, 2008

I confess to being a fan of Maggie Mahar's Health Beat posts. In Health Care Spending: The Basics; Spending on Physicians' Services-Do We Spend Too Much? Part II, she detailed meticulously what lies behind the 22% of the $2.1 million spent last year on physician services. I agree with her that income disparities between general practitioners and invasive cardiologists, radiologists, and some surgical specialties need to be resolved. Many contracting decisions about physician compensation seem arbitrary and capricious to me.

As a practicing general surgeon, I maintain that the distinction between cognitive practitioners and proceduralists is a false distinction. A spectrum of cognitive behavior is present across all branches of medicine. Cognition is not an on-off, all-or-none phenomenon, as the story below illustrates.

My father, George A. Cohn, was a neurosurgeon at the Buffalo General Hospital for 40 years until his death in 1991. Approximately 20 years ago, he was asked to see a SUNY undergraduate, who had been knocked unconscious in a frisbee football game. On the patient's CAT scan was a miniscule vascular malformation in an uncommon location, and the question asked was did this malformation contribute to the patient's loss of consciousness and should it be removed?

Because of the rarity of this malformation, my father consulted the literature and discussed the case with neurosurgical and neuroradiology colleagues throughout the country. They came to the hypothesis that the malformation and the loss of consciousness were unrelated and that the patient did not need surgery at that time, provided that he developed no symptoms from the vascular malformation.

The student's parents came from New York City to discuss their son's condition. After a brief introduction, my father said, "After conferring with colleagues across the country, I think,"

"What do you mean, 'I think,' Doctor," the patient's father interrupted, to which my father replied, "You should be damn glad that I think!"

In a specialty that would be labeled procedural, my father took a history, performed a physical examination, interpreted laboratory tests and brain scans in conjunction with colleagues, made a diagnosis, and derived a treatment plan in conjunction with the patient and family.

Like primary care practitioners, surgeons interview patients, perform physical diagnosis, review laboratory tests, and make diagnoses. In addition, we lead teams, coordinate both surgical and non-surgical care, and serve on hospital committees. Especially in fields like trauma and surgical oncology, many of the decisions we make involve non-operative care. Cognitive skills are equally important in the operating room, especially when "the patient does not read the book," i.e., there are unexpected findings at the time of operation that require sophisticated decision-making, i.e., judgment.

If I ever need surgery again, I will seek care from a competent, compassionate cognitive surgeon. The words "cognitive" and "surgery" are not an oxymoron.

January 22, 2008

I grew up in Buffalo, NY, where I saw some of the first Bills' games at my father's side. I sincerely hope that my writing about the Patriots in an admiring way does not cause him to turn over in his grave.

I cannot help wondering whether having an 18-0 record has as much to do with high-reliability systems as it does with outstanding coaching and players. High-reliability organizations (HROs), such as the nuclear power industry and large-jet commercial aviation, display the following characteristics (Amalberti et al. Five System Barriers to Achieving Ultrasafe Healthcare. Annals Int. Med 2005; 142(9):756-764):

HROs display a culture of trust, shared values, and communication in excess of norms to mitigate risk and achieve outstanding outcomes. According to Amalberti et al., only blood-banking and low-risk (ASA I) anesthesiology have outcomes comparable to the nuclear power industry and large-jet commercial aviation.

What do you think?

Are there policies and procedures where increased clarity could promote better clinical outcomes

Have we invested in and perfected cutting-edge performance measurement and tracking systems that give feedback in real time rather than months afterward

Can we learn valuable lessons from other industries, or should sports analogies be banned from healthcare

January 15, 2008

I enjoyed Christopher Cornue's writing about how to engage physicians in his post, Physician Integration- What Does This Mean? He talked about the need to marry physician and administrative leadership as supportive rather than exclusive managing (and leadership) styles.

In healthcare, as in academics, a group of independent professionals whose loyalties rest with colleagues and subject matter more than the organization, affect the organization's revenues, expenses, and outcomes.

The old paradigm that physicians have clinical responsibilities and administrators have financial and operational responsibilities is broken. With CMS and now hospitals in MA, MN, and VT not paying or charging for "never events" like wrong-site surgery, pressure sores, and injuries resulting from falls (among others), we need to act as though physicians and hospitals are joined at the hip and cannot achieve error-free care without working together.

It took years of meetings of healthcare professionals at the Pittsburgh Regional Health Initiative before questions shifted from the accusatory, "Why don't you...?" to a more systems-based reflection, "What if we...?" Download Socioec4_06.pdf("Socioeconomic Issues Affecting Healthcare Collaboration, p.48, in Cohn KH. Collaborate for Success! Breakthrough Strategies for Engaging Physicians, Nurses, and Hospital Executives. Chicago: Health Administration Press, 2006), http://www.ache.org/pubs/redesign/productcatalog.cfm?pc=WWW1-2067

Please share your thoughts about what assumptions and actions limit our ability to collaborate in healthcare. How would you fill in the question, "What if we ...?"

January 14, 2008

At my birthday dinner in downtown Boston, my 17-year old daughter surprised me at the end of the meal with, "So old man, what have you learned in half a century?"

Knowing that we had only one car and that I had the keys, I mused, "First, when I finished my residency, I was consumed about my career. Now relationships matter to me a lot more than anything else." Her eyes rolled as if to say, "Duh, what took you so long?"

"Second, I learned that I could work very hard at a job that I loved, but that I couldn't expect the institution to love me back because it had its own priorities." She looked at me blankly.

"Third, --it happens, and it's nobody's fault." Her eyes lit up as if to say, "I can agree with that." It may have just been delight, however, to hear an adult swear in a tony restaurant.

"Finally, learning is never failure, even though it may feel like failure," to which she replied, "You are so full of trite expressions!"

As we drove home, I thought that batting 0.250 was good enough for the major leagues, especially with a teenager.

Comedians quip that adolescence is one reason that some mammals eat their offspring at birth.

What can we learn from adolescents that relates to healthcare collaboration?

does respect need to be earned with accountability rather than to be expected

should we ask "so what" or "what's in it for me" more often when thinking about how others will react to what we are saying

what type of listening skills do we need to practice to make people feel that they have our full attention in the moment

During residency, I was called to the Operating Room in the middle of the night. As I entered the room, I noted that an anesthesiologist was not present. I had been summoned to remove the corneas of a patient who had died, so that they could be available for corneal transplant before the body was taken to a funeral home. I had learned through experience "Never fight at night," and did what I was told.

The next day, I described the situation to my Chairman who listened, but did not share my outrage. Finally, I asked him, "What will it be, education or service?"

He smiled and asked me, "What will it be, inhalation or exhalation?"

"That's easy," I replied in sleep-deprived certainty, "You need to do both!"

"Exactly," he replied as he escorted me out of his office.

My only complaint about Ralph Jacobson's and Brian Campion's recent article, "Problem Solving: Not Good Medicine for Health Care" (The Physician Executive. Jan-Feb 2008, 55-60), Download ProbSolvingJacobson1_08.pdf, is that I wish that the authors had written it 30 years ago when I was in residency and saw events as moral absolutes.

The authors contend that what keeps healthcare leaders up at night is not their inability to solve problems but their inability to deal effectively with paradoxes, which they see as issues that defy simple solutions. They recommend treating dilemmas as processes to explore rather than problems to solve.

January 12, 2008

The thinking behind this category is to link current events in the news to topical issues affecting healthcare collaboration.

Even the President commented that one cannot run for election without claiming to be an agent of change. All the publicity about change made me wonder why most of the images regarding healthcare change are so negative.

A surgeon quipped, "Only a baby desires change!"

What are your thoughts? Do you agree with Harvard Business School Professor Rosabeth Moss Kanter that change is disturbing when done to us, but exciting when done by us?

In "Surgeon Frustration: Contemporary Problems, Practical Solutions," (Contemporary Surgery 69(2):76-85, 2003), Mike Peetz and I wrote that practicing surgery requires a lifelong commitment not only to improving clinical skills but also to developing effective interpersonal skills, such as communication, team-building, and conflict resolution.Download cs02031.FrustrationKHC.pdf

In "Tectonic Plates Are Shifting: Cultural Change vs. Mural Dyslexia" (Frontiers of Health Services Management 24(1):11-26, 41-42), Len Friedman, Tom Allyn, and I wrote that healthcare professionals may choose to respond to change in a defensive manner, that may feel protective but lead to mural dyslexia, the inability or unwillingness to see the handwriting on the wall. Download cohn_frontiers_241.1.pdf Frameworks can help us make sense of sytems and respond positively to the changes that disrupt our thinking and routines.

Ned Hallowell in "Crazy Busy:Overstretched, Overbooked, and About to Snap! Strategies for Handling Your Fast-Paced Life," (http://www.amazon.com/CrazyBusy-Overstretched-Overbooked-Strategies-Fast-Paced/dp/0345482441/ref=pd_bbs_sr_3?ie=UTF8&s=books&qid=1200147051&sr=8-3) pointed out that the antidote to worry involves:

sharing concerns with another person

obtaining the facts

formulating a plan of action

I hope that by creating a safe learning environment, we can share, learn, and deal with change collaboratively.

September 06, 2007

The word "collaborate" conveys two meanings. One derived from the Latin "collaborare," means to work together. The other connotes partnering with people who are not trustworthy, as in "collaborating with the enemy."

In this and subsequent blogs, let's explore this duality and how we can move from viewing life as a series of "us-versus-them" battles to a more Copernican view that puts patients and families at the center of the universe. Most of us went into healthcare initially to make a difference in patients' lives. Hence, we agree on the who and why; it is the how that is the source of a lifelong learning journey.

I hope that this blog will become an environment in which it is safe to share our ideas and in which learning will replace blaming. The idea for this blog stemmed from a need to allow people to reconnect who had come together during seminars that I have taught at the American College of Healthcare Executives on Practical Strategies for Engaging Physicians since 2003.

I want to hear your thoughts and needs. Please help us form a vibrant learning community that helps us sustain one another in our efforts to improve patient care.